DIFFICULT IV: 5 TIPS TO KNOW

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In this video I will demonstrate a technique for IV access in a patient in whom several previous attempts by different personnel failed. While we could use an ultrasound to insert a central venous catheter or a deeper seated IV, such as a brachial vein, here we demonstrate a simple technique of using an Esmarch that can be very effective for peripheral venous access in most patients with difficult veins.

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I'm an ICU RN and PACU RN and ever since I watched your videos, my PIV insertion success rate has increased to a 95% 1st attempt success rate. Bending the IV and taking time for the tourniquet to work is the key. I went from primarily using 20g ivs to 18g ivs. As well I placed my 1st 16g IV in a septic patient all because of your techniques. Thank you so much.

jameselroy
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As an Oncology RN our patient cohort is difficult. We use a heat pack whilst talking with them……also relaxes us both. I put the tourniquet on whilst I prepare my equipment. Usually works. I do have my favourite veins.

pennychurchward
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Hello Dr Hadzic. I am a French anesthesiologist, and since I have seen your old video, I systematically bend my intravenous catheter, which greatly improves my success. my colleagues are amazed, but it works. Thank you for your wise advice.

immobinvesting
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ER RN/Paramedic here-
I've used a manual blood pressure cuff, pumped up just above the diastolic reading to really get the distal vein engorgement in very difficult IV starts. The one bad thing about that- if you hit the vein but are unable to cannulate it, you will have a more impressive hematoma to deal with.

JohnOscar
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I am a military nurse and have worked in Anesthesia and ambulances. An important method to get peripheral veins a vue is to use heat packs. Especially in an outdoor, prehospital setting or in an A&E setting with elderly patients with insufficient peripheral perfusion.
I am going to give the Esmarch a try, though!

(Oh, and bending needles: I have been taught to do that for IV insertion, but also for local analgesia in small procedures)

Korporaal
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Greetings from Germany! Some weeks ago we got an 90 yo woman in the ER who felt down the stairs and laid there for some hours. She had massive decollement wounds on both hands and forearms and her head. External jugular access was no option due to the high insertion angle from a prominent mandibula and skinny neck. So I bent a short 18G to cannulate 1st a tibial leg vein and 2nd at her shoulder as seen in your videos. Your advice was great! :) btw: bending needles is common practice here too.

whcscomlat
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I am currently binge watching your channel because it will be my saviour during my renal medicine placement atm! Thank you! I used to suck at venipunctures but now I manage to bleed literally anyone, even one time my reg and the parent by bedside were impressed because the patient was known to have a difficult access. :")

Miral_oo
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A couple of comments. Excellent video and series. The Esmarch technique is a great idea. I'd like to add another technique which I have incorporated for a long time. This is to use forced-air warming to make sure the patient is warm and perfusing their distal extremities. Distal limb blood flow varies greatly depending on a variety of factors - anxiety and hypovolemia of course, but thermoregulatory state is as important, if not more so. Forced-air warming of the entire patient for about 20 minutes can make a huge difference. This is much more effective than just warming the arm or hand. When I've been called to place an IV on a patient on the ward, the first thing I do is feel the temperature of their hands while looking for veins. If the hands are cold, 20 minutes of "Bair Hugger" will make all the difference. BTW, I bend the needle all the time too. I would disagree with the idea of "inserting the needle quickly". One gives up tactile feedback and unless you are incredibly accurate every time, there may not be enough time to see blood return before puncturing the other side of the vein. Do veins actually "roll"? I don't think so.

fishtaster
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Thank you so much! 2:23 actually the needle is not aligned with the vein and I realised this was intentional to prevent the vein from rolling. Good technique!

alptekinakturk
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Just wanted to say thanks again for that "bend the needle" trick. I had to put an IV in a distal tibial vein today, and couldn't get the angle right even with the patient plantarflexing her foot. A little curve in the needle gave me the extra 5° I needed for a successful insertion. <3

mirandawilde
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Near impossible IV? Let's put an 18g in the hand. Amazing.

Farnsworth
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I'm baffled that medical staff don't know that if you raise the hand the blood volume in the veins goes down, so the natural remedy to thin veins is to have the hand pointed to the floor, just let it hang and only then use a band above the insertion site. Blood pools due to gravity, use it to your advantage.

jonjon
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I am a qualified medical dispencer. practice makes the person more and more better. how much you will old in this profession you will learn new and new techniques every day

yasirkayani
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Thank you very much for your advice. I will apply them as soon as I have the opportunity. However, in older patients with very fragile veins, I prefer not to use a tourniquet. I just press firmly on the vein with my index finger, wait for its volume to increase, and a few centimeters lower I insert the catheter in a quick but delicate movement. Pain and vascular damage are minimal.

monainfame
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Nice information. I have become dependent on ultrasound 😅 trying to remedy this

cardiyansane
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As a paramedic if I ABSOLUTELY need to get IV access for a unstable patient for medications I’ll go for the EJ if no other option is viable and I exhausted other methods. And obviously if the patient is unresponsive and absolutely necessary I’ll go for the humeral EZ-IO.

But thank you for your tips and videos, much appreciated!!

HamptonsStreetDoc
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Excelente todos los videos de esta serie, muchas gracias, igualmente por los subtítulos que ayudan mucho.

danieltrros
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Paramedic here. One of the first things I do after ABC’s is to place constricting bands on both of the patient arms. By the time we have the O2, monitor and misc done the veins have had 2-5 min to fill.

It makes the best of wasted time and helps b

Frankthetank-zrmc
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Elderly people do have sometimes thick vein walls and almost without a lumen, so it could be reasonable to use ultrasound not for guidance but for identification of the most suitable for successful puncture vein with the largest lumen ...

evgenyhomenko
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I have started using some of these techniques on the ambulance and have seen more success. In particular I tie the tourniquet first thing. While that dwells I get all my other iv stuff setup. Opening the packages, putting the extension set together and priming... after all that then I start looking for a vein.

danw